The effect of a distance education training program on nurse Interns' readiness for distance education and their perceptions of lifelong learning

Abstract Aim The purpose of this study is to assess the effect of a distance education training program on nurse interns' readiness for distance education and their perceptions of lifelong learning. Design A quasi‐experimental research approach with one‐group, pre/post‐test was used. Methods The study used a quasi‐experimental research approach and was carried out at Damanhour University's Faculty of Nursing. A study was carried out on 345 interns' students. All nursing interns enrolled in the 2020–2021 internship training year. The researchers employed a program that contained a distance education readiness assessment as well as a questionnaire about the perceived advantages of lifelong learning. Results The majority (99.7%) of nurse interns were highly ready for distance education, whereas only 0.3 percent were moderately ready following the training program implementation immediately. In comparison to pre‐training, the majority (91.9%) of them were somewhat ready for distance education, while just 7.2 percent were highly prepared. Furthermore, the majority (97.1%) of them had high total skills of distance education after implementation of the training program by 3 months, and 95.4 percent had high total skills of learning immediately after the training program, whereas 26.1% of nurse interns had high total skills before the training program, at p value 0.01.


| BACKG ROU N D
Distance education is described as "instruction and planned learning in which teaching generally happens in a distant location from learning, necessitating connection via technology as well as particular institutional organization" (Jowsey et al., 2020).Distance education is a relatively new kind of instruction that necessitates the use of modern technology.It is a popular format in educational settings because of its adaptability to students' requirements.It offers teaching and learning over long distances by utilizing some tools.Distance education has been the sole alternative to higher education to improve access for nurses who are unable to attend regular lectures (Tümen Akyildiz, 2020).The terms 'distance learning' and 'distributed learning' are sometimes used interchangeably because 'distance learning' suggests that there is a central institution from which the students are remote, while 'distributed learning' means that both the students and the institution are dispersed.That is, there are educators, offices, and places near the students who are part of the medical school in dispersed learning (WFME, 2021).

| INTRODUC TI ON
Higher education institutions utilize technology in various ways, but successful integration requires educators' acceptance.The goal is to promote inclusivity, drive innovation, and enhance efficiency, with technology being used in teaching techniques (James, 2014;Katz & Macklin, 2009).The use of technology in today's health education programs is a crucial learning opportunity for students, as it will first improve future health care professionals' preparation and, second, enable the development of professional skills that will prepare them for future job environments.Technological advancements have led to the development of distance education, which enables training at various times and locations without physical participation.This space-free approach has gained popularity and is now the fundamental design rationale in modern educational procedures, allowing individuals and collective structures to train at any time and location (Cousins et al., 2022;Nsouli & Vlachopoulos, 2021;Van Rensburg, 2018).
Nursing interns, experienced adult learners, are actively pursuing continuing professional education to expand knowledge and learn in the changing global market.They are self-directed, highly motivated, and driven by career advancement, employment stability, upward mobility, and personal motivations (Hossain et al., 2020).They understand why and what they need to study (Wei & Chou, 2020).
Adult learners, diverse in educational backgrounds and ambitions, often reflect on their experiences, influenced by their daily duties and varying expectations (Curran et al., 2019).As a result, there is a need for an educational environment in which adult learners may select their own educational processes, freely communicate their thoughts, and maintain their educational process alongside their personal life (Kara et al., 2019).
Distance education offers flexibility for nursing interns, allowing them to control their learning processes.To ensure learnercentered design, programs should address various learners' needs, including those of adults.Understanding the relationship between learners' characteristics and distance education environments is crucial for effective experiences (Dilmaç, 2020).Through distance education environments, learners may control learning processes anywhere and whenever they choose.Furthermore, they can participate in greater engagement using the tools (e.g., discussion and chat) provided by distance education environments (Sailsman, 2020).Distance education offers learners the ability to acquire virtual teaming skills, control their learning processes, and receive personalized training.It also provides life-long learning opportunities, supporting professional development programs zzcrucial for nurses' knowledge retention.This is a significant advantage for nurses in their professional development (Kara et al., 2019).

| Study significance
There is a global need to expand the number of graduates, particularly graduates in health sciences, because there is a global shortfall of 7.2 million healthcare professionals (Katz & Macklin, 2009).The growing demand for graduates necessitates increased accessibility to education.Distance education can be overwhelming for students with limited computer literacy and internet connectivity issues.
Successful assistance may be provided by determining the best remote education approach (James, 2014).From the perspective of nursing interns, the benefits of online learning include greater student satisfaction, motivation, problem-solving abilities, and higherorder thinking capabilities.The increasing participation of nursing interns in distance learning is driven by lifelong learning, equal access to courses worldwide, promotion, and flexibility.This growth necessitates increased attention to ensure the effectiveness of distance education programs and retention (Van Rensburg, 2018).
Because of its flexibility, distance education obviously offers learners the advantage of life-long learning.
Lifelong learners are in high demand in both the domestic and foreign labor markets.Furthermore, in order to become successful learners, lifelong learners require adequate advice, counselling, and support at all ages and stages of life and employment (Hossain et al., 2020).Lifelong learners are optimistic, curious, and enthusiastic about learning, relying on failures to understand what doesn't work.They are constantly aware of change and variation, utilizing their skills to question, reason, and assess (Wei & Chou, 2020).
Healthcare providers must regularly update their skills through lifelong learning, allowing for skill renewal and upgrading in healthcare settings.However, there is limited understanding about nurses' experiences and perceptions of lifelong learning, and there is no comprehensive global picture of how nurses interpret and experience it (Zhou et al., 2020).Students' readiness for distance education refers to their ability to execute learning activities through distance or in an online context (Roller-Wirnsberger et al., 2019).Technologymediated distance education offers cost-effective, adaptable, and extensive resources beyond the classroom, making it crucial for nursing education due to students' clinical placements (Moore, 2020).
There is a lack of studies in this field, as in some quantitative studies, they focused on the satisfaction of nursing students with e-learning and the experiences of students, managers, and educators have been investigated, but less experimental studies have been done in this area (Farsi et al., 2020(Farsi et al., , 2022)).So, the current study is among the first to investigate the effect of the distance education training program on intern nurses' readiness for distance education and assess their perception of lifelong learning in Egypt.Hence, there is an urgent need to investigate aspects including perception and preparation for distance education, as well as the perceived benefits of lifelong learning.The researchers aimed to assist learners in acquiring 21st century abilities and spark long-term educational growth.To achieve these objectives, embedded teaching programs must take on the responsibility for change in order to provide their learners with these skills and competencies.Therefore, the following hypotheses of the study were postulated: H1: Nurse interns' readiness for distance education will increase with their participation in the distance education training program.

H2:
The distance education training program will have a significant effect on nurse interns' perceptions of lifelong learning.

| ME THODS
Aim: the study aimed to assess the effect of distance education training program on nurse interns' readiness for distance education and their perceptions of lifelong learning.

| Research design
In this work, a quasi-experimental research approach with onegroup, pre/post-test was used.

| Setting
The study was carried out in the Faculty of Nursing, Damanhour University.

| Subjects and sampling
A non-probability sampling technique was applied using convenience sampling of 367 nursing internship students in the internship year 2020-2021 were recruited from one study setting in Egypt.Of them, 345 (96.6%) agreed to participate in the study and completed the self-administered questionnaire after the training program.
The inclusion criteria were the nursing internship students who were working in their clinical settings for not less than two months (Figure 1).

| Tool I: Distance education readiness questionnaire
The questionnaire was adapted and modified from Kara and Can (2019), Aleshkovskiy et al. (2020), and Bolliger and Halupa (2018) dimensions of distance education after doing a thorough analysis of the literature to identify whether a student has a high, moderate, or low degree of preparation for distance education (13,21,22) .It comprised two sections:

| Tool II: Perceived benefits of lifelong learning
The researchers developed this tool after doing a comprehensive assessment of the literature (10,12,14,16-18,23) .It composed of two sections: 1st Section: baseline knowledge on the concept of lifelong learning and, benefits of lifelong learning.
2nd Section: Perceived skills earned by lifelong learning; this section is divided into 5 subscales: curiosity (5 items), openness to learning (8 items), access to information and information literacy (4 items), self-direction and self-evaluation (6 items), and sustainability in lifelong learning (2 items).The higher the mean score, the higher the perception for lifelong learning, as the overall perception score is distributed as follows: low perception if the score is 25 to 49, moderate if the score is 50 to 70, and high perception if the score is 71 to 100.

| Tools adaptation
Since all participants were university graduates with English proficiency, questionnaires were constructed in the English language.
We employed various methods to evaluate their validity and reli-

| Construct validity
Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to assess the construct validity of the developed tools.
Kaiser normalization was used in conjunction with Promax rotation to conduct an exploratory factor analysis (EFA).The objective Steps in scale development (DeVellis, 2017).
of the EFA was to pinpoint the fundamental elements or dimensions that account for the variation in each questionnaire item's response.
The EFA of the distance education readiness questionnaire revealed a clear and consistent factor structure that reflected the two dimensions of the scale with high boldface loadings for all items, ranging from 0.544 to 0.943 which means that the items strongly contribute to their factor.The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.814, which indicates the appropriateness of the data for factor analysis and that there is a high degree of common variance among the items.
The EFA of the perceived benefits of lifelong learning questionnaire using Kaiser normalization revealed that there are two dominant sections that accounts for most of the variance in the responses.These factors have high loadings for all items, ranging from 0.634 to 0.745.This implies that it represents a general dimension of polychronic-monochronic tendency, and that all items measure the same construct.The KMO value is 0.856 for section and 0.871 for section 2, indicates that the data are very suitable for factor analysis, and that there is a high degree of common variance among the items.

| Reliability
The reliability of the tools was assessed using the corrected item-total correlations and internal consistency.
The corrected item-total correlations is the correlation between an item and the total score of the scale, excluding that item.It is a measure of how well each item fits with the overall scale.The corrected item-total correlations of the distance education readiness questionnaire showed that all items were positively and significantly related to their respective sections and to the overall score of the survey, ranging from 0.567 to 0.987.The corrected item-total correlations of the perceived benefits of lifelong learning scale showed that all items were positively and significantly related to the scale, ranging from 0.682 to 0.736.This means that all items are positively related to their respective subscales, and that they measure the same construct as the other items in the subscale.
Internal consistency, the Cronbach's alpha was used to measure the internal consistency of the tools.It is a measure of how well a set of items measures a single construct or dimension.It ranges from 0 to 1, with higher values indicating higher reliability and internal consistency.The Cronbach's alpha values for the distance education readiness questionnaire are 0.814 for the overall survey.The Cronbach's alpha values for all subscales perceived benefits of lifelong learning scale were 0.864.These results indicate acceptable reliability and internal consistency of the study tools.

| Fieldwork and data collection
Written approval was obtained from the identified faculty adminis- The duration of the study was four months in total for intervention and data collection, 2021.

| Ethical considerations
The researchers acquired ethical approval to perform the study from The Nursing Ethics Committee at Damanhour University's Faculty of Nursing (N: 63-2022).Following an explanation of the research aims and methods, each student participating in the nursing internship year provided individual informed permission.Students were informed that participation is entirely optional, that refusals or withdrawals have no ramifications, and that the information would be kept secret and would not influence their academic progress in the internship program.The findings reveal that there is a highly significance difference regarding nursing interns' readiness to distance education pre and post-intervention (p value <0.01).Moreover, the table shows that all (100%) studied nursing interns had high readiness to distance education post-intervention (after 3 months of the intervention).Also, the majority (99.7%) of them had high readiness to distance education, while only 0.3% of them had moderate readiness post-intervention (immediately after the intervention).Compared with pre intervention readiness, the majority (91.9%) of them had moderate readiness to distance education while only 7.2% of them had high readiness.
Furthermore, there is a highly significance difference regarding studied nursing interns' perception of lifelong learning pre and postintervention (p value <0.01).Regarding benefits of online learning, the majority (96.5%) of them had high total benefits post-intervention (immediately), and the majority (92.2%) of them had high total benefits post-interventions (after 3 months) compared with pre intervention only 28.1% of them had high total benefits pre intervention at p value <0.01.Moreover, the majority (97.1%) of them had high total skills of online learning post-intervention (after 3 months) and 95.4 of them had high total skills learning post-intervention (immediately), Moreover, there is a positive correlation between studied nursing interns' readiness for distance education Pre intervention and their perception of lifelong learning pre intervention (p < 0.01).Also, there is a positive correlation between studied nursing interns' readiness for distance education post-intervention (immediately) and their perception of lifelong learning post-intervention (immediately) (p < 0.01).Furthermore, there is a positive correlation between studied nursing interns' readiness for distance education post-intervention (after 3 months) and their perception of lifelong learning post-intervention (after 3 months) (p < 0.01).(Table 5).

| DISCUSS ION
The current study examined the effect of distance education training program on nurse interns' readiness for distance education and their perceptions of lifelong learning.The results verified that there is significant improvement in nursing interns' readiness for distance education, as evidenced by the fact that all of the nursing interns exhibited high readiness to online learning after the post-intervention tween students' perceptions and their readiness for e-learning.In addition, Kumar, 2021 (33) conducted a study on 155 students and found that learning readiness had a favourable influence on student satisfaction.

| Limitation of the study
The sample for this study was confined to one institution and one pre-test and post-test, therefore generalizability of the results is limited.Also, the current results are based on self-reported data, and thus, they are at risk of response bias and subjectivity.Despite this constraint, the findings of this study have implications for practice in the design of online learning and training that related assessment processes.Future longitudinal, experimental including intervention and control group, and multi-site studies may help to overcome these limitations.

| CON CLUS ION
The current study investigated the effect of distance education training program on nurse interns' readiness for distance education and their perceptions of lifelong learning.The results revealed 1st section: Section I: personal data as: 5 questions on personal data: gender, age, English fluency, availability of private work in F I G U R E 1 Consolidated standards of reporting Quasi-experimental study (CONSORT).Number of clients eligible for the study (follow up test=345 All clients' data analyzed Analysis addition to the following aspects: internship, grade point average (GPA) of the undergraduate program, distance education literacy profile as university training distance and/or distributed/online courses, number of received university training courses, self-training online courses, received self-training online courses, personal IT access, and personal internet access.2nd Section: Distance Education Preparation; this section included 24 statements and four subscales of skills (online student qualities, time management, communication, and technical) that assessed student readiness for distance education.Responses were graded on a four-point scale: strongly agree, agree, disagree, and strongly disagree.Reverse scores were assigned to statements 10, 15, and 21, for example; "I enjoy working face-to-face with other students in groups".The higher the mean score, the higher the readiness for distance education, as the overall readiness score is distributed as follows: low readiness if the score is 24 to 48, moderate readiness if the score is 49 to 67, and high readiness if the score is 68 to 96.
ability, such as following the Steps 1-6 of DeVellis' (2017) model for scale development (see Figure2) in relation to the coding instrument created.Clarification of the construct and development of an item pool were informed by a review of the literature review(Nifadkar et al., 2019;Thuan & Thanh, 2020).In addition, content validity, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), corrected item-total correlations, and Cronbach's alpha were applied.We used IBM SPSS software package version 22.0 and AMOS version 23.0 for the analyses.3.5.2 | Content validityA group of seven academics from the discipline, including three professors of information and data management and four professors of nursing administration.The panel identified word choice problems, typing errors, and punctuation errors.Several words were changed in response to their suggestions.In order to verify the accuracy and functionality of the instruments and determine the amount of time needed to complete study questionnaires, a pilot study with 35 nursing interns of the previous year to investigate the knowledge questionnaire's stability over time and showed a high positive significant correlation (r ranged from 0.782 to 0.862).The study sample did not contain the pilot sample.
3.5.4| Confirmatory factor analysisCFA was done using structural equation modelling (SEM) for the mean and standard deviation of the two scales used in the study (distance education readiness, and perceived benefits of lifelong learning).The CFA aimed to test the fit of the factor structure derived from the EFA to the data.The CFA confirmed that the model fit the data very well (comparative fit index [CFI] = 1.000, incremental fit index (IFI) = 1.000, root mean square error of approximation (RMSEA) = 0.117, Model X 2 = 5.120, p = 0.001*).
Data were fed to the statistical package of social science(SPSS,   version 24).Socio-demographic characteristics presented with frequencies and percentages.Mean and standard deviation (SD) describe the studied variables.The readiness for distance education and the knowledge pre and post training program implementation were tested using Friedman test to address H1.X 2 Chi square test was used to compare the pre-test/post-test levels and its relation with the sociodemographic.Pearson correlation coefficient analysis (r) was utilized to test the relationship among variables to address H2.All statistical analyses were applied using an alpha of 0.05.The normality of data distribution was tested as the Shapiro-Wilk test was used to determine the normality of the data.
tration for data collection.The study was executed over two main phases: pre-and post-intervention phases.The pre-intervention phase involved a pre-test and content development for distance education training sessions, while the post-intervention phase included a post-test (two times, immediately after the training program and after 3 months of the training program) and data analysis.Study participants were required to respond to questionnaires concerning distance education and lifelong learning before and after the intervention.During the pre-intervention phase, the nurse interns introduced the pre-test questionnaires to assess their knowledge of the study variables before implementing the training sessions.The researchers prepared the content and handout based on reviewing the related literature and participants' learning needs of pre-test results.A handout was revised by academic experts and distributed among nurse interns.Arrangements for sessions' time and place were decided with the nurse interns according to their work schedules and workloads.(Table1).During the first session, the researchers established a rapport with the nurse interns and presented the objectives of the training sessions, distance education definition, overview, principles, elements, benefits, techniques, and advantages.Also, relate information literacy to lifelong learning ability, sustainability in lifelong learning, and applying open access map to international distance education training programs.The researchers explained the distance education process, facilitators, and hinders/barriers for execution in the educational institutions within the second session.In the third session, the relationship between distance education and lifelong learning was discussed besides getting participants' feedback and reflection on the sessions.The content was presented online through Microsoft team using appropriate and collaborative teaching strategies (brainstorming, lecture, video presentation, and small group discussion).The researchers implemented 12 sessions to embrace all content to all participants.Most of the sessions were implemented in the morning duty, and few sessions were implemented in the evening shift.During the post-intervention phase, the post-test questionnaires were introduced instantly after the third session for each group to assess the changes in nurse interns' knowledge of distance education and lifelong learning.Every participant took around 30 min to complete the questionnaires by sending the link of the questionnaires on the official university e-mail of the nurse interns.

(
after 3 months of the training program).In addition, following the initial session, the great majority of them demonstrated a high level of readiness for distance education.Only a fraction of them exhibited great readiness compared to pre-intervention readiness.These findings were linked to the success of the training program offered by the researcher, which was based on the requirements of nursing interns at the time of pre-assessment.These findings are backed by Liu (2019) study, which employed a one-group pre-test-post-test approach, 445 pre-test and 624 post-test datasets, and discovered that the independent samples t-test results revealed statistically significant increase in student readiness abilities for distance education.Tsai, 2020 also discovered that competency-based learning has a good influence on learning readiness and distance education experience.Furthermore, Pete et al., 2017 demonstrated that, while students' psychological readiness for e-Learning was strong, they lacked technological and equipment readiness.Furthermore, Şenyuva and Kaya (2014) conducted research on 162 second-grade children in Turkey and discovered that the difference in students' readiness for self-directed learning before and after the web-based course was statistically and highly significant.In terms of perspective of lifelong learning, the current study found that nursing interns' perceptions of the benefits of distance education and lifelong learning skills increased immediately after the training program and after 3 months of its implementation.These findings might be attributed to the researchers' use of effective teaching approaches to allow access to knowledge and the usage of commonly used phrases, as well as to provide a chance for questioning.The results go in line with Kim et al., 2021 who conducted a quasiexperimental design on a sample of 164 senior nursing students and discovered a substantial gain in understanding of distance education and learning flow in the post-test.Furthermore, according to Rouleau et al., 2019, the impacts of e-learning are mostly recorded in terms of nurse responses, knowledge, and abilities (ie, the first two levels of the Kirkpatrick model).The usefulness of e-learning interventions for nurses in a continuing education environment in terms of how the learning may be transferred to modify practice and influence patient outcomes is uncertain.Swaminathan et al. (2021) conducted a study on 158 entry-level nursing graduate students in Chennai, India, and found that the majority of them are confident in accessing internet information.Willingness to study online, prior experience with distance education, and perceived benefits of the online component may all impact a learner's readiness for lifelong learning.There was a significant difference between the examined nursing interns' readiness for distance education before and after the training program.These findings are consistent withHerguner et al. (2020), who conducted a study on 306 university students and discovered that learners' distance education attitudes had a beneficial influence on their readiness for lifelong learning and continuous education.According toDiab and Elgahsh (2020), there is a large statistically significant negative link between the challenges that nursing students face and their view of e-learning.Furthermore,Mallı et al. (2021) discovered a strong positive relationship be-

Table 2
clarified that the mean age of the studied nursing interns' is 22.66 with SD 0.865.Most (80.9%) of them were female while, only 19.1% of them were male.Regarding English fluency, more than half (54.8%) of them were very good at English while less than one-fifth (19.7%) of them were excellent.Moreover, nearly one-fifth (22%) of them had a private work.Concerning grade point average (GPA), more than half (55.4%) of them were very good one-third (33.3%) of them were excellent.Also, more than three quarter (76.1%) of them received one university training course and 15.8% of them had two while only 8.1% of them had three courses.It also reveals that only 29.0% of then had self-training online courses and 36.0% of them had nursing procedure self-training online course.Furthermore, more than three quarter (75.7%) of them had personal IT access, and the vast majority (91.6%) of them had personal internet access.
Study Framework.
TA B L E 1 while only 26.1% of them had high total skills pre intervention, at p value <0.01.(Table4).
Nursing interns' level of readiness for distance education (pre-and post-intervention).Nursing interns' level of perception of lifelong learning (pre-and post-intervention).
TA B L E 3**Highly significant at p < 0.01.